Provider Demographics
NPI:1407189285
Name:STAM, KATHRYN M (CNM)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:STAM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 S ONEIDA ST STE 107
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5331
Mailing Address - Country:US
Mailing Address - Phone:920-432-0031
Mailing Address - Fax:920-432-2260
Practice Address - Street 1:2605 S ONEIDA ST STE 107
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5331
Practice Address - Country:US
Practice Address - Phone:920-432-0031
Practice Address - Fax:920-432-2260
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
176B00000X
WI148857176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI61363OtherDEAN HEALTH INSURANCE
WI61363OtherDEAN HEALTH INSURANCE